Septate uterus: reproductive outcome after hysteroscopic metroplasty.

OBJECTIVE: To evaluate hysteroscopic metroplasty and its effect on reproductive outcome. STUDY DESIGN: Seventy-five patients consulted for uterine septum between January 1996 to December 2000 at "La Sapienza" University in Rome were included in the study. RESULTS: Forty patients attempted pregnancy and a total of 30 spontaneous pregnancies resulted (75% pregnancy rate). The uterine cavity was normal at hysteroscopic follow-up in 68% of cases. CONCLUSION: Correction of uterine septum improves pregnancy outcome of patients. Broadening the indications for hysteroscopic metroplasty should be encouraged for patients who desire to conceive.

Serum and peritoneal fluid CA-125 levels in patients with endometriosis.

OBJECTIVE: To evaluate CA-125 in peritoneal fluid (PF) as an indicator of endometriosis. DESIGN: CA-125 levels in paired serum and PF were determined by the one-step immunoradiometric assay. For peritoneal samples, high dilution of the sample (1:100) was used to avoid false low results, caused by the "hook effect" phenomenon. PATIENTS: Forty-one women with and without endometriosis, undergoing laparoscopy or laparotomy during the follicular phase of the menstrual cycle, were selected. SETTING: 2nd Institute of Obstetrics and Gynecology, University of Rome "La Sapienza," Rome, Italy. MAIN OUTCOME MEASURE: Peritoneal fluid CA-125 levels obtained using diluted samples were significantly higher than those found using undiluted ones. RESULTS: CA-125 levels in PF were approximately 100 times higher than those found in paired serum, ranging from 970 to 10,636 U/mL. In patients with endometriosis, CA-125 levels in PF were significantly elevated when compared with the control group. In serum, CA-125 levels increased only in advanced stages of endometriosis. CONCLUSIONS: The sensitivity of the CA-125 test for endometriosis in PF is greater than in serum. Therefore, the measurement of CA-125 levels in PF could be useful in the detection of early stage endometriosis, which tends to be overlooked by the CA-125 serum test.

Vaginal reconstruction by skin grafts: a scanning electron microscopic evaluation.

In order to evaluate the morphofunctional pattern of transplanted skin structural and ultrastructural studies on biopsies taken from surgically created neovaginae in three cases of vaginal agenesis were performed one and two years postoperatively. Two of the cases were associated with a rudimentary uterus, while the remaining one involved testicular feminization. Neovaginae were constructed by directly prolonging a pre-existing perineal introitus, to form a vesicorectal pouch, which was lined inside with gluteal skin autografts. All three patients reported satisfactory psychosexual behavior one year after operation. Light microscopy of the bioptic fragments demonstrated, even two years after surgery, features generally similar to those of the normal dermis and epidermis, and a keratinization rate as a rule, that did not range significantly from the norm. Scanning electron microscopy also confirmed the maturation of the cornified cells, since these were often seen to be desquamating and exhibited structures usually found in normal skin, such as double edges on the luminal surface--usually considered to be the morphological expression of squamous cell overlapping--and microwrinkles on disrupted apical and basal cytoplasmic flaps, which are considered reciprocal cell-gearing devices. Our results seem to indicate, therefore, that the transplanted skin, maintaining, on the whole, its integrity and viability despite an environment differing somewhat from the external one with regard to moisture, pH and temperature, shows a good adaptability, at least until the above mentioned time lapses.

[Premature ovarian failure: etiopathogenic evaluation and therapeutic possibilities]. / Deficit ovarico prematuro (POF): inquadramento nosologico e possibilità di terapia.

Premature ovarian failure (POF) is a syndrome due to many etiologies, whose underlying mechanisms aren't completely understood yet. Consequently there are important therapeutic implications. The authors describe their experience treating patients with POF using hormonal replace therapy and ovulation induction therapy in order to restore or replace the early loss of reproductive capacity.

[Peritoneal cyst. A case report]. / Cisti peritoneale. Caso clinico.

Cystic mesothelioma is a rare benign tumor of the abdominal and pelvic peritoneum, consisting of solitary or multiple cysts. No more than 130 cases are reported. Several risk factors such as chronic peritoneal irritation, caused by foreign bodies, infection or endometriosis, were hypothesized but the pathogenesis is still unknown. A 51-year menopausal woman was submitted to ultrasonography because of abnormal uterine bleeding. The scan revealed a right ovarian cyst (size 81 x 64 mm) with the feature of serous cyst. In the anamnesis a cystectomy of the right ovary and appendectomy were reported. At laparoscopy, then converted in laparotomy, a cyst arising from peritoneum of the posterior surface of the uterus was found. The right ovary was normal. The histopathological finding was: serous simple cyst of peritoneum. Ultrasonographic diagnosis was not confirmed by surgery; in fact, sometimes, it may be difficult to establish the origin of pelvic cystic mass, from ovary or peritoneum, by ultrasonography. It is mandatory to suggest a laparoscopy and/or laparotomy in case of pelvic cystic mass that does not regress in the time even after administration of oral contraceptives.

[A rare case of ectopic pregnancy. Primary ovarian pregnancy]. / Raro caso di gravidanza ectopica. Gravidanza ovarica primitiva.

A rare case of primary ovarian pregnancy is reported. The multiple diagnostic problems and the unclear symptomatology delayed the time of the definitive diagnosis more than seventy five days. All the histological criteria for the classification of an ovarian pregnancy are faced in this case. The finding of a well conserved gestational sac and embryo inside the ovarian tissue makes this case even more rare and interesting. When there is a suspicion of ectopic or ovarian pregnancy the Authors strongly suggest an early laparoscopy to make a reliable and precocious diagnosis, avoid the risk of the hemoperitoneum, perform a conservative therapy and preserve the ovarian function with the patient's reproductive potential.

[Psychosomatic sterility. Search for a hypothesis for personaity structure using Moretti's graphology method]. / Sterilità psicosomatica. Ricerca per una ipotesi di struttura di personalità con la metodologia grafologica morettiana.

Over the past three years the authors have performed a random clinical study on couples who came to the aim of identifying the possible presence, in those cases in which it was not possible to pinpoint an organic or functional etiological factor, of a relationship between personality structure and so-called "sterility sine cause" which according to the recent studies by Pancheri and Zichella on reproductive emotionality, is thought to caused by a factor of psychosomatic origin, The substantiality of the concept of reproductive emotionality, otherwise referred to as sexual instinct, was put forward in 1962 by Padre Gerolamo Moretti, a leading figure of Italian graphology. Research to date, carried out using traditional methods of clinical psychology, interview and tests, in an attempt to determine a particular personality profile, has not produced completely satisfactory results. From the literature it does not appear that graphological analysis has been applied in research of this nature. Graphology, if used by competent and appropriately trained persons, is certainly a powerful and refined diagnostic method which enables an idiographic, holistic and integrated personality profile (intelligence and temperament) tp be obtained for the subject in question. Moretti's temperament classification was used to define the personality structure of patients: assault, resistance, assignment and expectation. Research using graphological techniques has revealed that it is possible to define a personality structure within which suspected "sine cause" patients may be classified. In comparison to the control group, there was a prevalent attitude expressing a tendency to reserve, introversion, diffidence, anxiety, excessive and sometimes unmotivated concern regarding persons and things, attachment to one's own ideas, inflexibility of one's own position, scarce capacity to make oneself available, excessive attention to formal aspects. A number of practical considerations also emerged from the research: the good level of acceptance and compliance with the diagnostic instrument used and the fact that the patient in question does not necessarily have to be present. Due to the ease of obtaining an example of the patient's handwriting, graphological analysis could be outinely requested as the first approach in suspected cases of sterility due to psychosomatic causes.

Menstrual patterns, pain symptoms, body mass index and smoking habits in women with endometriosis.

Epidemiologic studies have investigated the risk factors for endometriosis, but currently the results are still controversial. The aim of this study is to evaluate the incidence of some of the risk factors that have been involved with endometriosis to better understand the natural history and evolution of this disease. The medical records of 186 women with laparoscopic diagnosis of endometriosis were studied. We analysed the characteristics of the menstrual cycle, the presence of pain symptoms and the familiarity for endometriosis. Moreover, the body mass index of all patients and the average cigarettes smoked per day were calculated. Despite the fact that some of the data collected resulted to be statistically significant when compared among the four stages of endometriosis, the roles of the many factors that have been associated with the risk or the evolution of pelvic endometriosis still remain unknown.

Ovarian blood flow before and after conservative laparoscopic treatment for endometrioma.

To evaluate the vascular changes in ovaries affected by endometriomas 28 women with ovarian endometriosis underwent transvaginal ultrasound with color flow imaging and blood flow analysis of the ovarian artery before and after laparoscopic conservative treatment of the ovarian cyst. Mean pulsatility index (P.I.) and resistance index (R.I.) of the ovarian artery on the side affected by endometrioma were compared using Student's t-test. Mean P.I. after laparoscopy (1.59) was significantly lower (p = 0.001) than before surgical intervention (2.17). Analogously the mean R.I. was significantly different (p = 0.001) when compared before (0.81) and after (0.73) laparoscopy. Color Doppler velocimetry may add greater understanding of the ovarian hemodynamic changes that occur after conservative surgery on the ovary.

Laparoscopic treatment of ovarian endometrioma. One year follow-up.

Thirty-six women with ultrasonographic diagnosis of ovarian endometrioma (bilateral in nine of them), have been treated laparoscopically. After the surgical procedure the patients were assigned to one of the following regimes: Gn-RH-a for 3 months, oral contraceptives if they wanted to avoid pregnancy, or nothing. The follow-up consisted in 1-3-6-12 months ultrasound. The first recurrences were observed at the 6-month ultrasound with an overall recurrence rate after 12 months of 11%. Improvement of pain symptoms occurred in 87% of the patients and fertility rate was 45%.

Comparison of local injection of methotrexate and linear salpingostomy in the conservative laparoscopic treatment of ectopic pregnancy.

STUDY OBJECTIVE: To compare local injection of metothrexate (MTX) and linear salpingostomy in the conservative laparoscopic treatment of ectopic pregnancy. DESIGN: Prospective, nonrandomized study, July 1991 to May 1994. SETTING: Department of obstetrics and gynecology in a university hospital. PATIENTS: Fourteen women with unruptured ectopic pregnancies without documented fetal heart motion and size below 50 mm as measured by ultrasound. INTERVENTIONS: All 14 women underwent the laparoscopic treatment by either local injection of MTX or linear salpingostomy (7 patients each). MEASUREMENTS AND MAIN RESULTS: Both treatments were successful in all patients. Mean length of operation was 32 +/- 5 minutes (range 25-35 min) in the MTX group versus 67 +/- 15 minutes (range 50-90 min) in the salpingostomy group. Mean length of hospital stay was 2.7 days (range 1-5 days) and 1.7 days (range 1-3 days), respectively. No intraoperative complications occurred, and the postoperative course was uneventful in all women. Mean disappearance time of serum beta-human chorionic gonadotropin (hCG) levels was similar in both groups, although in the linear salpingostomy group the decrease was immediate. No difference in tubal patency on follow-up hysterosalpingography was observed between the two groups. CONCLUSIONS: Although this is a preliminary report with a small number of patients, both types of treatment were safe and effective. An advantage of linear salpingostomy was the predictable and consistent decline of circulating beta-hCG, and consequently a reduced need for a close follow-up. Local MTX injection was safe, economic, effective, and easy to perform, and in our experience the surgical time was statistically shorter than that for linear salpingostomy. Therefore, in selected patients, local injection of MTX could be the treatment of choice for unruptured ectopic pregnancy, avoiding a longer and potentially more dangerous procedure. Long-term outcomes do not seem to differ between the two types of treatment.

Operative Laparoscopy for Adnexal Cystic Masses in Patients Under 40 Years of Age

From January 1990 through October 1993, 527 patients under 40 years were submitted to operative laparoscopy for the treatment of 544 adnexal cystic masses by stripping or vaporization/coagulation techniques in nine centers in Rome. The mean age of patients was 27.8 years, ranging from 13 to 39. The mean diameter of the cysts was 45.8 mm. ranging from 20 to 130. The procedure was completed by laparoscopy in 518 cases (95.2%) whereas 26 cases (4.8%) were converted to laparotomy. Conservative treatment was performed in all cases except 6 (1.1%), where ovariectomy or adnexectomy was performed. Histopathology revealed a borderline tumor in two; in all others the cyst was benign. It is concluded that operative laparoscopy is the procedure of choice for the treatment of carefully selected adnexal masses in patients of reproductive age.